URINALYSIS & BODY FLUIDS (HLD 22403)

PLEURAL , PERICARDIAL AND PERITONEAL ANALYSIS By Mr. Hanan

PLEURAL FLUID ANALYSIS

Routine examination of Pleural fluid. Physical examination Chemical examination Immunological examination Cytological examination Specimen collection Procedures

Introduction
Pleural fluid is obtained from the pleural cavity, located between the parietal pleural membrane lining the chest wall and the visceral pleural membrane covering the lung. Pleural effusions may be transudative or exudative.

Transudates & Exudates

Exudates are fluids, cells, or other cellular substances that are slowly discharged from blood vessels usually from inflamed tissues. Transudates are fluids that pass through a membrane or squeeze through tissue or into the extracellular space of tissues. Transudates are thin and watery and contain few cells or proteins.

Differences Between Transudate & Exudate

Characteristics Transudate Transudate - Clear,Straw yellow Sp gravity :< 1.018 Protein :< 2g/dl Inflammatory cells :Low Count

EXUDATE Appearance: cloudy may be clotted Color: yellow to red Sp gravity :> 1.018 Protein:> 2G/DL Inflammatory cells: High count

Specimen Collection

Specimen Collection
Fluids for laboratory diagnosis are collected by needle aspiration. EDTA tube is used for cell counts and the differential. Sterile heparinzed evacuated tubes are used for microbiological and cytology. Chemistry test can be run on clotted specimen in plain tube or on heparinized tubes .

Specimen Collection

Physical Examination
Volume: Measure and record the volume of fluid received. Appearance, color, clot formation: Note color whether clear or cloudy, or whether clot is formed on standing

Chemical Examination
Chemical test that are performed are usually compared with plasma chemical concentrations because the fluids are plasma filtrates. Therefore blood specimen are usually obtained at the time of collection. Protein estimation Glucose estimation

NEUBAUER COUNTING CHAMBER

Count in the four corners

Count in the four corners

Cells in one corner square

MESOTHELIAL CELLS

BENIGN MESOTHELIAL CELLS

FOAMY MACROPHAGES

INFLAMMATORY PLEURAL FLUID

Microbiology Examination
Microorganism that area usually associated with pleural effusions are Staphylococus aureus , Enterobacteriaceae, Mycobacterium tuberculosis. Gram stain, cultures (both areobic and anerobic) acid fast and mycobacteria cultures are performed. Serological testing of pleura fluid is used to differentiate effusions of immunologic origin from non inflammatory processes. Test for antinuclear antibody(ANA)and rheumatoid factor (RF) are most frequently done.

Immunological Studies
ANA (Anti Nuclear Antibodies) titres are useful in diagnosing effusion due to SLE, and rheumatoid factor is commonly present in pleural effusion associated with sero - positive rheumatoid arthritis

ACID FAST BACILLI

CANDIDA IN PLEURAL FLUID

Cytological Studies
Distinguishing characteristics of malignant cells may include nuclear and cytroplasmic irregularities , hyperchromic nucleoli, cellular clumps and abnormal nuclear to cytoplasmic ratios.

Abnormal mitosis

SMALL CELL CA

ATYPICAL PLASMA CELLS

Pathophysiology of Pericardial Effusion:

The pericardial space normally contains 15-50 mL of fluid, Lubrication------ for the visceral and parietal layers Originate from the visceral pericardium an ultra filtrate of plasma. Total protein levels are generally low The cause of abnormal fluid production underlying etiology secondary to pericarditis. 1.Transudative ---obstruction of drainage (lymphatic) 2. Exudative -------inflammatory infectious malignant autoimmune processes within the pericardium.

CAUSES OF PERICARDIAL FLUID ACCUMULATION

Infectious
Viral (coxsackievirus A and B, hepatitis, HIV) Pyogenic (pneumococci, streptococci, staphylococci, Neisseria, Legionella species) Tuberculous Fungal (histoplasmosis, coccidioidomycosis, Candida) Other infections (syphilitic, protozoal, parasitic)

Noninfectious
Acute idiopathic Uremia Neoplasia
Primary tumors (benign or malignant, mesothelioma) Tumors metastatic to pericardium (lung and breast cancer, lymphoma, leukemia)

ROUTINE EXAMINATION
Physical examination: Colour. Clot formation. Specific gravity: Altered colour is seen in Bacterial pericarditis,Tuberculosis, SLE, Rheumatoid pleuritis, Lymphoma, carcinoma.

Chemical examination:
Includes test for glucose and proteins Glucose- decreased in rheumatoid inflammation& purulent infection. Lactate- elevated in bacterial infection pH- decreased in pneumonia not responding to antibiotics. Amylase-elevated in pancreatitis, esophageal rupture and malignancy.

Cytological Examination
Includes WBC count RBC count, Differential count Malignant cells.

Microbiological Examination
Grams stain AFB stains Pericardial fluid culture

Sample Collection
Normally -10-50 ml Excess fluid ---pericardial effusion. Fluid is obtained by using a sterile needle under aseptic precaution called as pericardiocantisis.

Peritoneal Fluid
Accumulation of fluid between the peritoneal membrane is called ascites, and the fluid is commonly referred to as ascitic fluid rather than peritoneal fluid.

SPECIMEN COLLECTION
Abdominal paracentesis: The removal of 5 L of fluid is considered large-volume paracentesis. Total paracentesis, ie, removal of all ascites (even >20 L),

Routine Examination
PHYSICAL EXAMINATION: Transparent and tinged yellow. A minimum of 10,000 red blood cells/L is required for ascitic fluid to appear pink, more than 20,000 red blood cells/L is considered distinctly blood tinged. Bloody fluid from a traumatic tap is heterogeneously bloody, and the fluid will clot. Nontraumatic bloody fluid is homogeneously red and does not clot because it has already clotted and lysed. Neutrophil counts of more than 50,000 cells/L have a purulent cloudy consistency and indicate infection.

CHEMICAL TESTING
Chemical testing- is primarily glucose, amylase and alkaline phosphates determination. Glucose low below serum levels in bacterial and tubular peritonitis and malinancy. Amylase-to ascertain cases of pancreaititis Elevated alkaline phosphates-is highly diagnostic of intestinal perforation.

Cytological examination:
Cytology 58-75% sensitive Malignant Cells sediment is smeared on slides. Papanicolaou stain and Leishman stains A cytospin preparation can be used for clear fluid. .

Cell count: Normal <500 leukocytes/L < 250 polymorphonuclear leukocytes/L. A neutrophil count > 250 cells/L - highly suggestive of bacterial peritonitis. In tuberculous peritonitis &peritoneal carcinoma a predominance of lymphocytes usually occurs.

Microbiological examination:
Culture/gram stain is performed when bacterial periontitis is suspected. AFB stain may be done if required.

MESOTHELIAL CELLS

MALIGNANCY IN ASCITIC FLUID